Thursday, September 06, 2007

Resident work hours

Resident work hours is a buzz phrase used in medical education. About two years following the completion of my residency, there were new rules implemented to try to limit the hours worked my interns/residents. (image credit)

The theory behind this was that interns/residents would not be as tired and would make less mistakes. And, less mistakes would mean less patient deaths (less mortality).

Data just published from the University of Pennsylvania state that since the implementation of resident work hours, mortality rates have not decreased as expected. (WebMD)

The findings "reinforce the impression that there is still not clear evidence for an effect of duty hour reforms on [patient] mortality," suggests an editorial in The Journal of the American Medical Association by David O. Meltzer, MD, PhD, and Vineet M. Arora, MD, of the University of Chicago.

Now, I wouldn't consider myself "old school," but (cue old guy accent) when I was in residency, we didn't have these resident work hour rules. We were on duty until the work was done.

I know that I probably have talked about this before on the blog, but working all those hours during residency really got me ready for my practice now. To be honest, I think I'm working more hours now than I did in residency.

Not only did I learn about clinical issues and diseases in residency, I learned how to try to balance life at work and life at home. I learned how to try to function on less hours of sleep. And, most important, I learned my limitations when I was feeling fatigued.

I could be wrong, but I think these residents being trained today are being sheltered too much and not getting a true taste of what life will be following residency. When they get in the real world, they're going to learn very quickly that there are no work hour rules.

I feel that the American health care system will not feel the real impact of these resident work hour changes for many years. What kind of American medical workforce will have been created with these rules in place? I guess we'll just have to see.

6 comments:

being on duty until the work gets done means the work actually gets done. the small matter of continuity of care. my brother got operated in the first world country of sweden. every day there was a new clueless doctor to see him. he had to scrounge around through the other people's notes just to figure out what was going on before adding his two cents worth to the chaos.

i am also old school and that is not because of some macho 'i went through it so so must they' attitude, but i believe it is better for the patient (the person we pretend to be helping when we cut working hours although we actually all know we do it for the doctors)

But what's wrong with doing it for the doctors? If you have a consistent day team and a consistent night team, that serves continuity at least as well as a rotating system of 3-5 residents on call. Everybody has to leave eventually. Also, does it really make sense or seem humane to have anybody work more than 24 hours in a row? What's wrong with looking at what's humane for the people doing the work?

Also, at least in obstetrics, we rarely sleep on call (there is as much going on at night as during the day, basically), and I suspect the same is true in other specialties. I know that I am not the same doctor after being in the hospital for 30 hours. My priorities shift from "What can I do for the patients?" to "How can I get this done the quickest or avoid it in a safe manner so that I can get to bed?"

Additionally, studies (the Harvard work hours study) have shown that extended shifts (>24 hours) are DANGEROUS for the workers, that there are 2x as many fatal and non-fatal car accidents after extended shifts. They also show a significant increase in medical errors, however it seldom effects patients because there are more well rested pharmacists and nurses and other physicians involved in the care of the patients.

Just because patients don't die from people working 30 hours + in a row doesn't mean that it's a good idea. I agree, there are some benefits to extended shifts, but there's also no reason anybody should ever work more than 24 hours in a row.

#1: In my opinion, the study from Univ of Pennsylvania is a waste of time. The reason is that there are ga-zillion of confounding factors can affect the [patient] mortality than just the resident's working hours. So even if the study's found patient mortality improved, it still is a meaningless result. There is no "actual" meaningful conclusion can be inferred from such study; unless there is nothing else has been changing in those hospitals where the data was collected; i.e., there is no new procedures, equipment changes, no new nurse, no new etc.....

#2: "Midwife with a Knife" has a wonderful point. You make more mistakes as the hours get longer. That is no brainer. Although Harvard did a study to prove it, it does not need an actual study.

#3: The author seems to imply that the new generations of physician would be worse than those who were trained before the duty hours changed; because [perhaps] the new ones would not learn as much with the new duty hours. I hope the author did not commonly work 14-18 hrs/day and at the same time, study for his school exams, board exams, and licensing exams. If he did, that proves two things. He learns better, remember more with long working hours [I doubted]; AND he is a supper....doc!

#4: Though the author might think that his long working hours has prepared him for the real world and work, I am pretty sure that he continues learning new things and new surprises every day; and so will the new residents when they go out to the real world, (regardless that they were trained with 150 hrs/week or 80 hrs/wk during residency). There is no ideal working hour can prepare a resident for everything. Information, guidelines, practices, and protocols change everyday. We all continue to learn after the residency. One might ask “if so, then why do we cut the working hours?” I guess probably because it is time to let the poor bastard residents have a break. Let the “real” doc of the “real” world to work a “real” long hours and bring home “real” bucks!

residency work hours in the u.s. were a true shock for me, a european med student. this is crazy. you were working 100-110 hours per week and know you are discussing about reducing them to 80? and you think 80 is too little? wow... let me tell you this: here in europe we embrace quality and not quantity. all those residency work hours wont make you better doctors. stop believing in these fairytales they feed you just to take advantage of you. personally, i was thinking about going to the u.s. for my residency. but now that i read this, i say no way.. i ll stay in europe. and guess what. we ll become excellent doctors as well, without having to sacrifice our lives..

Resident work-hour restrictions are a must and they are only going to be enhanced over the next few years. Medicine is not the same as when you old guys were in residency...it is far more complicated! To read more, go to: http://www.associatedcontent.com/article/1288635/resident_work_hour_restrictions_impending.html?cat=5